Nutrition and Intake among Women with Anorexia Nervosa: Counseling should address total intake.

Reprinted from Eating Disorders Review
July/August Volume 26, Number 4
©2015 IAEDP

Prolonged dietary restriction is at the heart of AN, and nutritional counseling and treatment are essential. However, getting an accurate picture of the nutrient intake of an AN patient is far from easy and is often prone to error, according to Susan K. Raatz, of the USDA Human Research Center, Grand Forks, ND, and colleagues at the University of Minnesota, the University of North Dakota, the Neuropsychiatric Research Institute, Fargo, ND, and the University of California-San Francisco. Dr. Raatz notes that attention has been focused on reduced intake of energy and macronutrients, while few studies have described total micronutrient intake in patients with AN.

Dr. Raatz and colleagues assessed total reported energy and nutrient intake in a sample of women 19 to 30 years of age, with both restricting and binge-purge type AN (Nutrients. 2015. 7:3652). They then compared their results with the reported intake of a representative group of women who participated in the “What We Eat in America” portion of the National Health and Nutrition Examination Survey (NHANES) 2011-2012. Participants with either binge-purge or restricting-type AN were assessed with structured interviews, and their BMIs were determined.

To obtain detailed 24-hour dietary recall information, all participants were surveyed in telephone interviews on three separate occasions by trained interviewers using a structured nutritional interview, the NDS-R. To provide a comparison, the nutrient intake of non-pregnant women aged 19 to 30 years was derived from the 2011-2012 WWEIA/NHANES survey.

The mean age of participants was 22.5 years, and the average BMI was 17.2 kg/m2. Intake of most nutrients was insufficient but some participants reported high intake levels when compared to Dietary Reference Intake levels. Some participants may have inaccurately recorded their intake because reported intakes for some exceeded estimated energy needs, even though these participants maintained very low body weights. 

The authors suggest that counseling for AN patients be centered upon total food intake, to improve energy intake and to lessen individual gaps in nutrition.

Disturbed Endocannabinoid Responses to Hedonic Eating Detected Among AN Patients: Physiologic dysregulation may be the culprit.

Reprinted from Eating Disorders Review
July/August Volume 26, Number 4
©2015 IAEDP

Two main components drive eating behavior: maintenance of energy balance (homeostatic eating), and the rewarding or pleasurable qualities of food (hedonic eating). Italian researchers have uncovered what may be a dysfunctional reward mechanism in a small study of 7 underweight and 7 weight-restored patients with anorexia nervosa (AN) (Am J Clin Nutr. 2015. 101:262).

Endocannabinoids are a set of naturally occurring brain substances that impact mood, learning, appetite, and brain plasticity. Food ingestion is periodically controlled by the endocannabinoid system. As Dr. Alessio Maria Monteleone and co-authors point out, in particular, hypothalamic and mesolimbic endocannabinoids are produced after food deprivation, and increase appetite by stimulating neurochemical pathways underlying both homeostatic and hedonic eating.

In an earlier study by the same researchers, hedonic eating in healthy subjects increased concentrations of ghrelin and 2-arachidpnoylglycerol, suggesting that these two markers modulated food-related reward (J Clin Endocrinol Metab. 2012; 97:E917). In the current study, the authors once again investigated the physiologic modulation of food-related reward, but this time studied patients with active AN and weight-restored patients with AN. The authors assessed peripheral endocannabinoid responses to hedonic eating in these patients, and compared these levels to those established in the previously studied healthy participants. Levels of other mediators were also measured, including two receptors whose activation, in opposition to that of cannabinoid-1, may reduce food intake and reward.

Patients with AN who were consecutively admitted to the eating disorder inpatient unit of Villa Garda Hospital, Naples, Italy, were screened for the study. All those selected for the study met DSM-IV criteria for past or present AN. 

To test hedonic and non-hedonic eating, before the first session all participant were asked to indicate his or her favorite food, a food they would eat just for pleasure, even when full. Through a series of steps, including a 12-hour fast, the participants rated their hunger and satiety on a visual analog scale. Blood samples were dawn immediately after exposure to the favorite food and within 10 minutes after the individuals freely ate their favorite foods. In the second procedure, participants were exposed to a non-favorite food and had to eat an equivalent amount of it.

Unexpected results

Surprisingly, in both hedonic and nonhedonic eating sessions, no significant difference emerged between groups in scores of hunger, satiety, urge to eat, or in the pleasantness of experiencing a mouthful of the presented food and the amount of food each participant would eat. In all groups, hunger and satiety scores before hedonic eating did not differ from those before nonhedonic eating, whereas scores for the urge to eat, pleasantness of experiencing a mouthful of the presented food, and the amount of food eaten were significantly higher before eating the favorite food than before eating the non-favorite food

When the authors compared the results from their study of underweight and weight-restored AN patients to earlier levels established from normal-weight healthy controls, they found altered plasma concentrations of 2-arachidonoyglycerol after hedonic eating in both groups of AN patients.

These results need to be replicated and extended, but they support the idea that responses of the endocannabinoid system to hedonic eating appear to be disturbed and may play a role in AN.

Compulsory Refeeding for Severely Ill AN Patients: Extreme measures worked for one group of critically ill patients.

Reprinted from Eating Disorders Review
July/August Volume 26, Number 4
©2015 IAEDP

Effective treatments for AN are badly needed, particularly for adults, according to Christoph Born, MD, and a team at Ludwig Maximillians-University in Munich, Germany. These researchers recently described their group’s novel intensive care approach for severely ill patients with AN, a program involving mandatory hospitalization, guardianship, and for some, installation of a percutaneous gastric feeding tube (BMC Psychiatry 15:57, 2015.). 

A study group with extremely low body weight

The authors reported on a group of 68 patients with AN who were severely underweight and who had been admitted to their hospital between 2000 and 2013; relapse and remission were common. Seventy-five percent of participants had BMIs under 13 kg/m2 on admission. Legal guardianship was established on the basis of Bavarian law. Patients were offered regular meals and a percutaneous gastric feeding tube was recommended (84% received them). 

The percutaneous feeding tube was thought to have several advantages over a nasogastric tube, including avoidance of damage to the nose or upper GI tract. In addition, patients were able to take food orally, and the tube could be used for supplementary feeding. Other important considerations were potentially decreasing the chances that patients could manipulate or remove the tube and minimizing the stigma. All the AN patients were required to participate in common meals on the ward. Gastric tube feeding with a high-caloric solution (up to 3000 kcal/day) was provided on an individualized basis. The primary goal was to help patients attain a BMI of 17 by gaining 700 to 1000 gm per week.

Tube feeding was halted once the patient reached a BMI of 17, and the feeding tube was removed after body weight remained stable for 2 weeks. Aftercare within a specialized ED setting was then arranged.

Was the extreme program effective?

Dr. Born reported that 84% of the patients had a percutaneous gastric feeding tube implanted; 3 had nasogastric tubes inserted; and 8 had neither because of contraindications. Mean BMI at admission was 12.3, and this rose to a mean of 16.7 at discharge. Duration of illness was shorter and weight gain during treatment was higher in those with restrictive type AN (ANR group) than in those with binge-purge type AN (ANBP group). 

Treatment lasted significantly longer in those with feeding tubes, but those without a feeding tube were younger, had been ill for a shorter time (7.3 vs. 9.9 years), and had slightly higher admission BMIs. Patients who attained the BMI goal of 17 were actively encouraged to seek further therapy. Those with ANBP were more likely to seek treatment in a psychotherapeutic or psychiatric hospital than were patients with ANR

The authors concluded that patients with severe AN can be successfully treated using a guardianship and tube feeding regimen such as theirs. They added, however, that little is known about the long-term outcome of AN patients after refeeding programs are completed, and they correctly note that the amount of lasting cognitive change is unknown. Furthermore, the goal BMI (17) represented a clinically significant change in this severely ill group, but was still a very low target BMI. 

The authors referenced an earlier 13-year follow-up program of 484 adult patients with AN in which 60.3% of patients had fully recovered, 25.8% had good outcomes, 6.4% had bad outcomes, 6.4% had a severe outcome, and 1.2% had died (Diabetes Metab2011; 37:305). In that study, 8 factors were linked to the lack of recovery at 2 years: low BMI at discharge, low energy and low fat intakes, high drive for excessive exercising, high scores for perfectionism, interpersonal distrust and anxiety, use of tube feeding, and poor adherence to treatment.

Parent Caregivers Need TLC, Too: Four areas of need were highlighted in a small study in Ireland.

Reprinted from Eating Disorders Review
July/August Volume 26, Number 4
©2015 IAEDP

Serving as a caregiver has challenges; being a caregiver to an adolescent with anorexia nervosa (AN) can be even more difficult than usual. Parents of AN patients face stigma, lack of access to services, ignorance about AN, and limited support. A recent pilot study by two researchers at Trinity College and St. Patrick’s Mental Health Service, Dublin, Ireland, examined some of these issues (Arch Psychiatr Nurs. 2015. 29:143).

Four key themes

Carol McCormack and Edward McCann discovered four key themes when they recruited a small group of parents of teens with AN who were being treated at an outpatient clinic in Ireland. 

The first area of concern had to do with the family environment, where parents reported that “all aspects of family life were affected” by the illness. While families felt that the illness had initially “taken over” the family, this feeling gradually waned as the teen began to recover. Communication within the family, including how the young patient should be “managed” or supervised, and conflicts about stigma and guilt were all important themes.

A second area of concern was the psychosocial impact upon the parents, particularly social, technical, and emotional components. Restrictions on family meals away from home were a source of frustration, as meals tended to be limited to settings acceptable to the adolescents. One finding was that parents who spent more time at home reported a greater number of significant disturbances than did those who worked outside of the home.

The third area of concern surrounded quality of care and the sometimes-negative experiences with available services. Some parents and their children had been to general practitioners who had dismissed the teen’s problems or seemed unaware of available treatment options, and other parents and teens were frustrated by the delays in finding appropriate help. A fourth area was the need for more information or referral to a support group, which parents felt would have been very beneficial to them.

Finally, despite the challenges of care-giving, parents also clearly articulated that they were able to recognize positive aspects to the illness, including the hope of recovery, development of inner strength, and improved family communication.

The researchers stressed that their study results point to an urgent need for additional information and support for parents, so that they may better cope with a child with an eating disorder. In addition, they noted that professionals in non-specialist areas may also benefit from additional skills training.

Augmentation Therapy for Inpatients with Anorexia Nervosa: Two atypical antipsychotics boosted the effects of SSRIs.

Reprinted from Eating Disorders Review
July/August Volume 26, Number 4
©2015 IAEDP

Effective treatments for adults with AN remain elusive, and the results of pharmacologic treatments have been particularly discouraging. Recently, researchers in Italy reported that augmentation of SSRI therapy with an atypical antipsychotic, aripiprazole, helped reduce eating-related obsessions and compulsions among a group of hospitalized patients with AN (PLOS One doi:10.1371,journal.pone. 0125569 April 29, 2015).

Dr. Enrica Marzola and colleagues at the University of Turin’s Eating Disorders Center for Treatment and Research, Turin, Italy, revisited the use of the atypical antipsychotics olanzapine and aripiprazole as augmentation agents of selective serotonin reuptake inhibitor (SSRIs) in adult inpatients with AN. The authors selected the two atypical antipsychotics based upon the neurobiology of AN. This included alterations of dopamine and serotonin in pathways to the brain; the dopamine-blocking properties of these agents; weight and body shape; and their positive effects on safety, anxiety, eating psychopathology, and on depression. The authors also noted that one effect of some atypical antipsychotics is increased appetite and food intake, enhancing weight gain. 

Dr. Marzola and her team hypothesized that augmenting treatment with SSRIs with atypical antipsychotics could be more effective than SSRI monotherapy, particularly in the case of patients with depression and obsessive-compulsive disorders. To study this, the authors did a retrospective chart review of patients hospitalized at their eating disorders center between January 2012 and May 2014. 

All subjects were assessed with the Structured Clinical Interview for DSM-IV Axis I disorders and were included in the study only if they had AN. In addition, all participants had been taking an SSRI for at least 6 weeks at admission and had either olanzapine or aripiprazole added as augmentation therapy while hospitalized. Patients were excluded who were receiving a different category of antidepressant, or who had lifetime use of any antipsychotic or mood stabilizers, or who had been hospitalized due to a comorbid Axis I disorder, or with certain medical comorbidities. 

Measures included body mass index (BMI, kg/m2), weekly incidence of binge-purge behaviors, including use of diuretics or laxatives, and the amount of daily physical exercise. Anxiety and depression were measured with Hamilton scales for Anxiety and Depression and the Yale-Brown-Cornell Eating Disorders Scale.

One-hundred eighty-seven charts were reviewed, yielding a final group of 75 patients. Mean age was 25 years; mean BMI was 13.9, and the mean duration of illness was 6.9 years. All patients were receiving SSRIs (sertraline, citalopram, escitalopram, or fluoxetine) when they were admitted to the treatment center. After analysis, three treatment groups emerged: 32.9% remained on SSRIs as monotherapy; 32.0% received adjunctive aripiprazole; and 35.5% received adjunctive olanzapine. 

Differences emerged in the treatment groups

While the sample was not randomized to treatment condition, there were no differences by age, gender, BMI, or by AN subtype, duration of illness, exercise, or use of diuretics. Significant improvements emerged across the three treatment groups. Those in the aripiprazole group had significantly greater improvement on the global score and both subscales of the Yale-Brown-Cornell Eating Disorders Scale compared with the two other treatment groups. 

Clearly there are limitations to this study (including the small sample size and lack of randomization, for example). Nevertheless, the results support continued investigation of aripiprazole. They may also find a way to conceive of the role of medications in AN by targeting individual symptoms (in this case, ED-related cognitions and rigidity) as opposed to targeting AN as a whole.

Stepping on the Scale: Not Such a Simple Process: Identifying and overcoming resistance from patient and therapist alike.

eprinted from Eating Disorders Review
July/August Volume 26, Number 4
©2015 IAEDP

Two British psychologists present an intriguing analysis of a seemingly simple and routine step in treatment that is actually very complex: weighing patients. Drs. Glenn Waller and Victoria A. Mountford of the University of Sheffield, Sheffield, UK, and King’s College, London, focused on current protocols for weighing patients during cognitive behavioral therapy, or CBT (Behaviour Research and Therapy 70 (2015), 1-10). 

A starting point for their research was the marked variability in evidence-based therapies, particularly statistics showing that fewer than 40% of CBT clinicians routinely weigh their CBT patients (Int J Eat Disord. 2014 Dec 12. doi: 10.1002/eat.22369. [Epub ahead of print]. And, the authors found that a sizeable number of clinicians believed they should not share weight information with patients. Another issue was that many protocols do not directly address how, when, and why patients with eating disorders should be weighed. 

Four reasons why patients should be routinely weighed

Drs. Waller and Mountford cited four main reasons for CBT therapists to weigh patients with eating disorders: for patient safety, to understand the patient’s eating patterns, to reduce patient anxiety and avoidance, and to modify the “broken cognition” or the patient’s disconnect about the link between eating and weight gain. 

What is the best way to weigh CBT patients? One suggestion is to present the act of measuring weight simply as part of the therapeutic program, beginning with the assessment and the first therapy session. Presenting weighing as a rational and non-negotiable part of therapy will work with most patients, according to the authors, and only a few will question the rationale for it (i.e., ‘My last therapist did not weigh me.’). Exploring the reasons for weight change will help patients see such fluctuations in weight as a slow, boring process and to understand that most people gain or lose up to 2 lb even during the day. For anorexic patients, it is important to discuss the planned weekly weight gain target and to include this in future predictions and evaluations, according to the authors. Yet another suggestion from Drs. Waller and Mountford is that measuring weight be presented as a collaboration between patient and therapist.

The process of weighing

Some suggestions include reminding the patient--before she steps on the scales--that this is only one of four weight measurements used to establish an average weight. Another suggestion is that the patient and therapist view the scale weight at the same time. Then, whatever the weight and whatever the patient’s reaction, the goal is to treat the weight change as a long-term issue and not to get excited about it in the short term. 

Transparency is important, and the weight should be shared with the patient and copies of each weighing kept by both therapist and patient. The authors suggest including two lines on the chart, the actual weight, augmented with a median line every 4 weeks, and the cumulative weight. Then, outcomes after 4 weeks, as indicated on the weight chart, can be used to challenge false beliefs, allowing the clinician to stress the difference between the patient’s beliefs about gaining weight and the actual impact of eating. Thus, the ‘broken cognition’ is repaired with consistent, repeated focus on the eating-weight link. Then, at the end of the session, planning food intake (exposure to ‘feared foods,’ behavioral experiments) and related behaviors (reduction in purging behaviors) should be linked to the patient predicting likely weight change as a result. This prediction is repeated at the beginning of the weighing process at the next session, which will help deal with the fact that the patient’s predicted eating pattern at the end of the session might not be what was actually eaten over the intervening week.

Patient resistance and therapist justifications

Sometimes it’s not only the patient who is reluctant about the process of weighing. Some clinicians are reluctant to weigh patients, even when a shows no reluctance to approach the scale. Therapists’ justifications for not weighing patients may reflect a belief that this will ruin the therapeutic relationship. Or, such justifications many reflect an attitude that the patient is usually weighed by someone else anyway, or that the patient has already weighed herself before the session, or a belief that weight can be judged by eye, or There just isn’t enough time to do it.” 

The authors also found that some organizations have policies about weighing patients that are counter to effective delivery of CBT. Some everyday examples include weighing patients but not revealing the weight or asking other clinicians to weigh patients but then only asking for an update when substantial risk is identified. Some groups require that a patient be weighed only by a specific clinician and only on a particular day, making it impossible for a therapist to weigh a patient during therapy.

Adaptations for specific groups

Certain groups of patients, including inpatients, patients with high degrees of shame about their weight, morbidly obese patients, and those with medical complications, will need special adaptations for weighing. For example, at extreme levels, shame related to being weighed might interfere with the therapeutic alliance and with the individual’s ability to engage in therapy.

Finally, Drs. Waller and Mountford suggest that due to the diversity of current practices, future research should study the impact of training clinicians in the appropriate use of weighing. A second area of research involves the need for specific evidence that weighing is a necessary part of CBT. According to the authors, the overall goal would be to establish protocols that are clear about whether or not to weigh patients with eating disorders, and when and how to do so.

Comorbid Eating Disorders and Posttraumatic Stress Disorder: Implications for Etiology and Treatment

Karen S. Mitchell, PhD
Women’s Health Sciences Division, National Center for PTSD, VA Boston Healthcare System and
Department of Psychiatry, Boston University School of Medicine
Reprinted from Eating Disorders Review
July/August Volume 26, Number 4
©2015 IAEDP

The comorbidity of eating disorders, particularly those characterized by binge eating and/or purging, and posttraumatic stress disorder (PTSD) has been fairly well established.1 This association has been more frequently investigated among women. However, a recent investigation in a U.S. nationally representative sample found that 39.81% of women and 66% of men with a lifetime diagnosis of bulimia nervosa (BN) also met criteria for lifetime PTSD. In this study, 26% of women and 24% of men with a lifetime diagnosis of binge eating disorder (BED) met criteria for a diagnosis of lifetime PTSD.2

Childhood sexual abuse is also considered a nonspecific risk factor for eating disorders,3 meaning that it also precedes the onset of other disorders. More recent studies that have investigated multiple types of childhood and adult traumas have found consistent associations with eating disorders.1 In one of our earlier studies, we found that most women with lifetime anorexia nervosa (AN; 71%), BN (78%), and BED (63%) had been exposed to at least one form of interpersonal trauma, including physical or sexual assault, mugging, kidnapping, or witnessing familial violence.2

Although men are understudied in eating disorders in general, as well as in investigations of comorbid PTSD and disordered eating, evidence suggests that men with eating disorders may have significant trauma histories as well. In Mitchell et al.’s 2012 study, all the men with lifetime histories of BN had experienced interpersonal trauma, as had 68% of men with AN, and 74% of men with BED.2

The Connection between Trauma/PTSD and Disordered Eating 

Several potential mechanisms link trauma/PTSD and disordered eating. Exposure to trauma is a criterion for the development of PTSD.4 Trauma also may play an etiologic role in the development of depression, eating disorders, substance use disorders, and borderline personality disorder.4-7 Stressful life events may also play a role in the development of eating disorders.8 In addition, PTSD and eating disorders may share biological vulnerabilities, including dysfunction in the hypothalamic-pituitary-adrenal (HPA) axis, which has been associated with chronic stress.9Generally, exposure to trauma may contribute to global psychophysiological dysregulation, increasing risk for development of psychopathology.10 Binge eating and purging also may be used as forms of self-medication, enabling an individual to cope with symptoms of negative affect.11 The act of binge eating may produce a dissociative-like state of disinhibition,12 serving as a form of emotional numbing or avoidance. Of note, use of disordered eating to regulate negative affect may be particularly characteristic of individuals high in impulsivity,13 a trait that has been associated with PTSD14 as well as BN.15

How Body Image Is Affected By Trauma

There also may be direct links between exposure to specific types of trauma and body image. Interpersonal trauma may negatively impact one’s body image, as demonstrated by findings that women with histories of sexual assault have more negative images of their physical selves than do women without sexual assault histories.16 Sexual abuse may lead women to develop more critical views of themselves, thus leading to body image disturbance.17 It has been hypothesized that some women with a history of sexual assault wish to be thinner in order to minimize their secondary sex characteristics and to appear less attractive to potential perpetrators.18 Conversely, although this has been less well studied, victims of sexual assault may engage in binge eating in order to gain weight and thus to appear less attractive or to look stronger, in an attempt to “arm” themselves against potential perpetrators. 

Choosing the Best Treatment Approach

To date, no treatments have been developed specifically for clients with comorbid PTSD and eating disorders. However, because PTSD and eating disorders share many common biological and psychological features, it is possible that treatment for one disorder could result in improvement of symptoms for the other. Cognitive behavioral therapies (CBTs), including CBT-Enhanced for Eating Disorders (CBT-E )19 and Cognitive Processing Therapy for PTSD (CPT 20)20 are recommended for both disorders. CPT has two forms, one that involves a written trauma narrative plus cognitive therapy to challenge and address problematic cognitions about the trauma, one’s self, and the world, and a second form, CPT-C, that uses cognitive therapy without the written trauma account. Both are effective treatments for PTSD.21

Clinicians treating patients with these comorbid disorders often must determine which disorder to treat first, or whether to blend treatment approaches and to address both disorders at the same time. The specific approach selected depends in part on the severity of the eating disorder symptoms, which have the potential to be dangerous and even life-threatening.22 In less-urgent situations, case conceptualization, in addition to the patient’s preference, may guide the choice to treat one disorder before the other. 

Case formulation may be an especially useful tool for describing interrelationships among PTSD and eating disorder symptoms and associated variables.22, 23Essentially, the patient and clinician diagram the patient’s symptoms as well as contributing factors, to determine the mechanisms that link them. In some, perhaps milder, cases of comorbid disordered eating and PTSD, the eating disorder symptoms may have developed solely as a maladaptive coping mechanism. In this case, treating the PTSD first, while continuing to monitor eating disorder symptoms, could result in remission of the disordered eating symptoms. In addition, CPT involves 12 treatment sessions, and PTSD symptoms may remit quickly. 

Sometimes Referral Is Needed

Some of the cognitive exercises in CPT could focus on the impact of the trauma on the patient’s eating disorder symptoms. However, clinicians without specific PTSD expertise may need to refer patients to another professional. In a recent study of women presenting for PTSD treatment, we found that although symptoms common to both PTSD and disordered eating, including impulse regulation, interoceptive awareness, interpersonal distrust, and ineffectiveness, improved following CPT, there were no changes in drive for thinness or bulimia symptoms.24 Thus, symptoms specific to eating disorders may require additional treatment following standard therapy for PTSD.

For patients with more severe eating disorder symptoms that could interfere with PTSD treatment, the eating disorder may need to be treated first. Specifically, nutritional rehabilitation may be necessary so that the patient can engage in psychotherapy.23 In addition, it may be possible to treat symptoms of both disorders using a blended approach.25 However, future research is needed to determine whether there is greater benefit to a sequential vs. simultaneous approach to treating comorbid eating disorders and PTSD. 

Future Research

Eating disorders have high rates of comorbidity with other disorders, including PTSD. To date, there are no established treatments for eating disorders and comorbid PTSD. Both PTSD and eating disorders can be extremely debilitating on their own. It is recommended that clinicians conduct thorough psychiatric evaluations, including assessment for trauma histories for patients with eating disorders, and to attempt to determine what, if any, role trauma may have played in the onset of the patient’s eating disorder. Severity of symptoms and case conceptualization may guide the choice to choose to treat either the PTSD or eating disorder first or whether to treat them simultaneously. Future research is needed to determine the best treatment options for eating disorders with comorbid PTSD and whether a sequential or simultaneous approach offers the greatest benefit. 

References

1. Brewerton TD. Eating disorders, trauma, and comorbidity: focus on PTSD. Eat Disord. 2007; 15: 285.
2. Mitchell KS, Mazzeo SE, Schlesinger M, et al. Comorbidity of partial and subthreshold PTSD among men and women with eating disorders in the National Comorbidity Survey-Replication study. Int J Eat Disord. 45: 307.
3. Jacobi C, Hayward C, de Zwaan M, et al. Coming to terms with risk factors for eating disorders: application of risk terminology and suggestions for a general taxonomy.Psychol Bull. 2004; 130:19.
4. Diagnostic and statistical manual of mental disorders (5th edition). Washington, DC: American Psychiatric Association, 2013.
5. Ehlers A, Clark DM. A cognitive model of posttraumatic stress disorder. Behav Res Ther. 2000; 38:319.
6. Kashdan TB, Breen WE, Julian T. Everyday strivings in war veterans with posttraumatic stress disorder: Suffering from a hyper-focus on avoidance and emotion regulation. Behav Ther. 2010; 41:350.
7. Litz BT, Gray MJ. Emotional numbing in posttraumatic stress disorder: Current and future research directions. Aust N Z J Psychiatry. 2000; 36: 198. 
8. Pike KM, Wilfley D, Hilbert A, et al. Antecedent life events of binge-eating disorder. Psychiatry Res. 2000; 142: 19.
9. Lo Sauro C, Ravaldi C, Cabras PL, et al. Stress, hypothalamic-pituitary-adrenal axis and eating disorders. Neuropsychobiol. 2008; 57: 95.
10. Wonderlich SA, Crosby RD, Mitchell JE, et al. Eating disturbance and sexual trauma in childhood and adulthood. Int J Eat Disord. 2001; 30:doi:10.1002/eat.1101.
11. Heatherton TF, Baumeister RF. Binge eating as escape from self-awareness. Psychol Bull. 1991;110: 86.
12. Engelberg MJ, Steiger H, Gauvin L, et al. Binge antecedents in bulimic syndromes: An examination of dissociation and negative affect. Int J Eat Disord. 2007; 40:531.
13. Fernandez-Aranda F, Pinheiro AP, Thornton LM, et al. Impulse control disorders in women with eating disorders. Psychiatry Res. 2008; 157:147. 
14. Miller MW, Resick PA. Internalizing and externalizing subtypes in female sexual assault survivors: Implications for the understanding of complex PTSD. Behav Ther. 2007; 38:58.
15. Fischer S, Smith GT, Anderson KG. Clarifying the role of impulsivity in bulimia nervosa. Int J Eat Disord. 2003; 33: 406.
16. Campbell JC, Soeken KL. Forced sex and intimate partner violence: Effects on women’s risk and women’s health. Violence Against Women. 1999; 5:1017.
17. Dunkley DM, Masheb RM, Grilo CM. Childhood maltreatment, depressive symptoms, and body dissatisfaction in patients with binge eating disorder: the mediating role of self-criticism. Int J Eat Disord. 2010; 43: 274.
18. Connors ME, Morse W. Sexual abuse and eating disorders: A review. Int J Eat Disord.1993; 13:1.
19. Fairburn, C. G. Cognitive Behavior Therapy and Eating Disorders. New York: NY: The Guilford Press, 2008.
20. Resick PA, Monson CM, Chard KM. Cognitive processing therapy: Veteran/military version. Washington, D.C.: Department of Veteran’s Affairs, 2008.
21. Resick PA, Galovski TE, O’Brien Uhlmansiek M, et al. A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. J Consult Clin Psychol. 2008; 76: 243.
22. Trent SA, Moreira ME, Colwell CB, et al. ED management of patients with eating disorders. Am J Emerg Med. 2013; 31:859.
23. Brewerton TD. (2008, May 1). The links between PTSD and eating disorders. Retrieved July 3, 2014, from http://www.psychiatrictimes.com/articles/links-between-ptsd-and-eating-disorders
24. Mitchell K, Wells SY, Mendes A, et al. Treatment improves symptoms shared by PTSD and disordered eating. J Traum Stress. 2012; 25: 535.
25. Pratt, E. (2011). Personal communication.

The Body Project Defined

By Alan Duffy, MS

The Body Project is a dissonance-based body-acceptance program designed to help high school girls and college-age women resist cultural pressures to conform to the thin-ideal standard of female beauty and reduce their pursuit of unhealthy thinness. Since its inception, The Body Project has been supported by more research than any other body image program and has been found to reduce onset of eating disorders.

The Body Project Collaborative was formed in 2012 by Dr.’s Eric Stice and Carolyn Becker to create new training opportunities for people interested in facilitating the Body Project. Dr. Stice created the Body Project and Dr. Becker pioneered the strategy of training collegiate peer-leaders to facilitate Body Project groups in university settings. To date, the Body Project has been used by numerous high schools and over 100 college campuses (sometimes under the names ‘Reflections: Body Image Program®’ in the U.S. and ‘Succeed Body Image Program®’ in the United Kingdom), and has been delivered to over 200,000 young women. Research supports the use of the Body Project not only with those who have elevated body dissatisfaction, but also in more diverse groups of adolescent girls and young women that include those with lower levels of body dissatisfaction.

Over the last two years The Body Project Collaborative has witnessed unprecedented growth. As information about the program continues to spread, more and more universities, non-profit organizations, and high schools are seeking training for the program. The Body Project Collaborative offers one and two day trainings that can be specifically tailored to meet the unique needs of any group.

The Body Project is backed by almost 15 years of quantitative research that demonstrate the program’s ability to decrease body dissatisfaction, thin-ideal internalization, eating disorder symptoms, dietary restraint, and negative affect.  A selection of these articles is referenced at the end of this article. In addition, qualitative feedback in the form of both professional and student testimonials gives an easily accessible voice to the applied effects of the program.

Examples of these powerful testimonials include the following from both a student and a staff member:

“I very much enjoyed this training and am so excited to implement it on my campus. Being a participant in the group, I was challenged to think about my own behaviors and thoughts about my body. It empowered me to accept my body and to model this acceptance to others. I think the structure of the program itself really forces participants to argue against the thin ideal in a way they never had, and in a way that helps them go out into the world and be body positive and body activists. Great program – it should be on all other campuses!”

A M, Student, Large Midwestern University

It was a great experience to attend the Body Project training as a professional! I absolutely loved bearing witness to the participants growing in their understanding of themselves, their insight about their own body image, and becoming more self-affirming and active in promoting a positive body image for others. Their letters to a younger girl were incredible! Throughout the training, the women took more risks by being vulnerable with the group and disclosing their own struggles, which not only made the group feel more connected, but also offered each of them the opportunity to grow all the more. I also enjoyed hearing their perspectives on thin-ideal pressures, comments they had heard from others, and their creative brainstorming. Each practice round, they got better and more confident at facilitation, and I think that they will make terrific peer leaders. Prevention efforts regarding body image/eating issues has long been a concern of mine and I feel optimistic about this program’s ability to make a big difference on our campus. I work with clients with eating disorders, but recognize the unfortunate widespread systemic negative body image that women have internalized, as well as the growing number of men with negative body image. I’m so excited that the Body Project exists, as it seems to have high potential for being very helpful in creating real cognitive shifts, a more positive body image, and a platform for involving others in creating larger systemic change.

H B, Clinical Psychologist, Large Mountain West University

The Body Project Collaborative aims to disseminate The Body Project to as many young women as possible at minimal cost. Full details of trainings for collegiate peer leaders and professionals from universities, high schools, and other settings can be found at http://www.bodyprojectcollaborative.com

Meal Support Therapy for the Outpatient Population: 6 Options to Explore

By Laura Cipullo, RD, CDE, CEDRD

When dieting has failed, your body has turned off, and your peers’ bodies and plates look different, how do you know what or how to eat? Whether you are stepping down from a higher level of care or need practice using internal hunger fullness cues, there are now outpatient therapeutic meal options supports to expose, teach, and/or support learning to eat. There is even research supporting the effectiveness of some of these therapeutic options that include exposure therapy specifically for individuals diagnosed with anorexia1 and mindfulness for clients with binge eating disorder.2 The meal support sessions can be in the form of an individual session, a group, or with a companion. Meals can be offered in different environments, whether in day treatment at an eating disorder facility, in the office during a session, or even at a restaurant. Meal support therapy is often times co-led inpatient by an RD and a LCSW or psychologist. However, in the outpatient setting, it’s typically one or the other for a number of reasons—including state laws. So how does one know what type of meal support system to choose or from what kind of leader they would benefit?

There are multiple modalities for eating therapy, including a self-attuned model, intuitive eating model, family-based model, mindful model, and traditional model. This article will discuss the different types of supportive meals and the strengths and weaknesses of each. There is no right answer or no right group. Each individual must determine what is best for his/her personal situation and what will be most beneficial now as well as in the future.

Self-Attuned Eating Group

Self-attuned eating stems from a feminist psychoeducational and psychodynamic model. Andrea Gitter, MA, LCAT, BC-DMT, of the Women’s Therapy Center Institute, relates it to “fine tuning one’s response to physiological hunger and satiation.” She shared that both women and men have the opportunity to get in touch with these states of body and mind “to allow one to become more emotionally literate, to be able to identify and challenge cultural mandates and develop a more integrated body/psyche/self.” The self-attuned model can be taught individually or in a group setting by a licensed mental health professional. Clients do not eat in these sessions; they are purely didactic. This is a great option for both women and men who have been failed by diets or have been unsuccessful in changing their relationship with their bodies. This body based approach does consider medical conditions and will refer to the dietitian for medical nutrition therapy as determined by the licensed mental health professional.

Strengths:

1. Helps to heal the relationship to food, eating, and the body/self
2. Can change obsessive/compulsive thoughts and behaviors in regard to food, eating, and the body/self
3. Promotes self-esteem and self-agency (because the person is the expert at determining her internal cues on what and when to eat)
4. Empowers women and their bodies
5. Is anti-diet

Weaknesses:

1. Requires time and patience
2. Misses the aspects of medical nutrition
3. Not appropriate for many clients with acute eating disorders; better suited for those with emotional eating or a history of yoyo dieting
4. Does not include meals
5. Does not include exposure therapy to “binge” or “unsafe” foods

From the WTCI website3:

“The self-attuned model introduces curiosity and compassion as alternatives to the punitive and restrictive methods women typically employ in their efforts to change their relationships with food and their bodies. Next, the group focuses on legalizing all foods and eliminating dichotomous thinking about food, such as good and bad, healthy and unhealthy, or permitted and forbidden food groups. Finally, the group addresses issues of body image and embodiment, including the symbolic meaning of fat and thin and how one’s ideas about and experiences of one’s body function psychologically, interpersonally, and culturally.”

Intuitive Eating Group

Intuitive eating is an approach that teaches you how to create a healthy relationship with your food, mind, and body—where you ultimately become the expert of your own body. You learn how to distinguish between physical and emotional feelings and gain a sense of body wisdom. It’s also a process of making peace with food—so you no longer have constant “food worry” thoughts. You begin to realize that health and your worth as a person do not change because you ate a so-called “bad” or “fattening” food.4 There are groups utilizing an approach based on IE principles; however, this is only appropriate for nourished individuals or those with access to their hunger and fullness cues. Intuitive eating recognizes that not everyone is ready or able to identify his/her inner cues and recommends “nutrition rehabilitation” under the care of a RD to assist in readying an individual.5  Mary Dye, MPH, RDN, CEDRD, CDN, LD/N, and nutrition director of Oliver Pyatt Center (a residential and transitional treatment facility) says, “we use an IE model however, in reality it is truly mindful eating we are teaching. We fully plate and expect 100% completion of the RD prescribed meals until the individuals are at 90% of their goal body weight and medically stable. We remind them that they are mindful eaters and with that comes eating when not hungry at times and eating past fullness at times (for instance needing a snack but not feeling hunger for it or needing to eat past fullness to meet needs in a meal). In meal support, we give feedback that is general, such as ‘you’re about right’ or ‘you need more.’ We don’t give specifics like ‘you need three more spoonfuls,’ we keep it broader to challenge them to check in with themselves and see if they can tolerate this non-specific style of directives.”

Strengths:

1. There are no labeled foods, hence no need for guilt
2. Employs a “Gentle Nutrition” model
3. Recognizes the need for “nutrition rehabilitation” before engaging in the IE model of body trust
4. Can be adapted for children and adults
5. Based on internal self-regulation

Weaknesses:

1. Difficult to read hunger and fullness cues
2. Hunger and fullness cues may be deregulated in a small percent of the population due to foods, blood sugar fluctuations, and hormonal changes
3. If trying this in a meal support group, clients may have different levels of hunger and fullness at the time of the group
4. Clients must determine the difference in emotional, behavioral, and physical hunger
5. Clients can be triggered by other clients’ amount of food eaten
6. Clients must be adequately nourished to use a true IE model.

Mindful Meal Support Therapy Group

With research-based evidenced supporting its effectiveness, especially in clients with type 2 diabetes6, mindful eating has been added to the list of meal therapies. Mindful meal groups typically start and finish with meditation. The purpose of this meditation is to first separate the chaos of the day from the act of eating a meal and to recognize when one is eating. Recognizing the act of eating helps to make a meal psychologically satisfying and also helps clients get in touch with the internal regulation system (aka hunger/fullness cues) and/or emotional hunger and fullness.

Mindful eating groups are a great way to practice what is taught in many nutrition sessions. Practicing mindful skills can also be used as a tool to decrease anxiety, increase body trust, and prevent fear of overeating and or binge eating. Clients in need of re-nourishing their bodies as well as those who are adequately nourished can employ mindful eating. After a mindful exercise when the individual recognizes his/her body’s state and is aware he/she is about to eat, the facilitator can help the clients use their five senses in their first bites. Again, this is to help the client learn these skills so that he/she can engage them on his/her own. With mindful eating, clients must eat even if they feel emotionally full or cannot tell what they feel because they understand that they physically need food. The RD can help the client in determining an “appropriate” amount of food when eating out at a restaurant. Eating in this outpatient setting helps clients learn to navigate menus, eat all foods, eat appetizers, entrees, and dessert at one mealtime, and not engage in symptoms. In an ideal outpatient environment, the LCSW, PhD, or PsyD would be present to help clients process their feelings before and after the meals.

Strengths:

1. Can be appropriate for different states of nutrition
2. Best if led by the LCSW and RD together
3. Teaches mindfulness before, during, and after the meal
4. Offers process time before and after meals
5. Depending on the facilitator, teaches “all foods fit” model

Weaknesses:

1. No certification for the facilitator teaching mindful practices
2. Clients can be triggered by other clients’ percent of meal eaten as this differs for each client
3. Can only be led by RD for undernourished clients in restaurant environment as portions are not predetermined
4. Ideal to have both RD and LCSW or PsyD/PhD co-lead
5. Often gets confused with Intuitive Eating

Traditional Meal Support Therapy Group

The original meal support therapy was part of the daily feeding environment provided in a higher level of care such as residential and/or partial hospitalization. As an extension of day treatment and intensive outpatient, MST began to be offered in isolation like any other outpatient group. In this traditional group, ideally both the therapist and a registered dietitian co-lead the meal. However, due to private practice legal constraints, many centers and practices now only offer either a therapist or an RD, but not both. Clients are given a standard meal with snacks or supplements depending on their individual nutritional needs. All clients are expected to complete 100 percent of their meals. “RDs are uniquely qualified to lead clients into a conversation exploring their internal regulators of eating including both physiological and psychological cues of hunger, fullness, appetite and satiety. Completing 100% of the meal is a very important guideline for clients to follow, particularly at the beginning of their treatment when hunger and fullness cues are functioning improperly and cannot be trusted,” said Laura Bennet, RD, of NYC. Bennet also stresses the importance of finishing the entire meal, “down to the last bite,” in order to challenge the rigidity and disordered thoughts of the eating disorder. When asked about the specific role of the RD at meal group, Laura shared, “RDs are often educated on food rituals (used to alleviate anxiety during a meal such as taking very small bites) and can provide the necessary redirection to keep the client feeling supported and on target.” These meals are typically offered continually, with the client’s coming and going based on the client and multi-disciplinary team’s decision. These meals typically last an hour and involve a pre- and post-meal check in and goal setting.

Strengths:

1. Offers an educational and supportive environment
2. Ensures client gets in one adequate meal daily
3. 100 percent meal completion prevents restriction
4. One-hour limits prevent deliberate delaying and/or lengthening of meals
5. RDs can provide nutrition education (for example, the need to eat carbohydrates for fueling the brain, which only uses glucose)
6. Therapists can help process fears related to feelings of emotional fullness

Weaknesses:

1. Eating in the company of others with eating disorders can provide an environment for comparing food intake and body size
2. Clients with high anxiety have the potential for panic attacks
3. One meal a day is not sufficient for adequate nutrition
4. Clients may refuse meals and trigger other clients
5. Client has the potential to use symptoms before and after the meal

Family Meal Support

Family meal support is used to help an individual of any age with an eating disorder (most evidence based on anorexia) consume an adequate amount of nutrition. “The family dynamic must be cohesive, stable and supportive,” says Stephanie Jacobs, LMHC. This individual must live with their family as the family and/or caregivers become the “feeders.” They are in charge of preparing, serving, and supervising meals in the home setting (or restaurant). The caregivers are always present to ensure that their child is able to eat their meal and/or snack. Mount Sinai’s Eating and Weight Disorders Program is well known for teaching and providing this type of meal support in the context of family therapy (Maudsley method) sessions. FMS expert Dr. Terri Bacow says, “Parents and or caregivers are to provide support and coaching to enable the child to eat. The caregiver may provide a blend of empathetic encouragement as well as firmness, telling the child that s/he may not want to eat, but really needs to do so. The parent/caregiver may remind the child that it is okay to want to avoid finishing a meal or eat certain foods, but that this is important for health.”

The following strengths and weaknesses (1-4) on Family Meal Support come directly from Stephanie Jacobs, LMHC, of the Mount Sinai Eating and Weight Program.

Strengths:

1. Creates/enhances a supportive environment to help the child eat and let others know the meal was finished
2. Healthy way to connect with family and share information outside eating issues (i.e. school, friends, trivia), which can lead to a stronger sense of family unity (i.e. bonding)
3. Can be a key way of distracting person from preoccupation with food, weight, and/or shape
4. Can provide a productive pressure to eat/finish healthy amount of food
5. Opportunity for others to model and normalize healthy eating behaviors

Weaknesses:

1. If the person is only triggered by peers, in which case family meal support may be helpful, but not enough to help the person get used to eating healthily with peers/others
2. If the family dynamic/system is in turmoil (i.e. high negatively expressed emotion, parents fighting, distressed sibling relationships), this can lead to more distress
3. If the person has demonstrated that he/she is capable of eating on his/her own and experiences the meal support process in itself as condescending/infantilizing
4. If person uses meal support in a destructive way (i.e. suggests or acts in a way that may cause harm to self, others, or property), in which case a higher level of care may be necessary
5. Medical nutrition therapy is not typically part of this model.

Meal Companion

The concept of eating with clients in a one-on-one environment became popular in 1995 when Ellyn Satter, RD, LCSW, first introduced the practice of eating with clients in session to teach eating competence. Since then, it has become a norm for dietitians and therapists to follow Ellyn’s example. I can attest to the value of Ellyn’s teachings in both her three-day workshop and manual called Treating the Dieting Casualty. It has since been taken outside of the office and into restaurants.

Many eating disorder specialists such as registered dietitians have been eating with their clients as part of a session or extension of a session for years. This allows the practitioner to identify food rituals, encourage food consumption, and promote accountability. This can also be an opportunity for a therapist to discuss emotional fullness and/or help clients with a history of trauma work through feelings brought on by taking in food.

Like a sober coach, there are now professionals (beyond the typical team) offering meal services in a one-on-one environment. This enables an individual to be accountable to an objective and trained coach or licensed health professional who can then share the individual’s progress with the team. These services are similar to a concierge service. Greta Gleissner, psychotherapist and co-founder of Eating Disorder Recovery Specialists, said, “our services are best utilized as an adjunctive support for clients who are stepping down in levels of care, or who are struggling in current outpatient level of care but want or need to stay in their environment.”

Strengths:

1. Offers client accountability for meals
2. Lessens anxiety surrounding meal time decisions for client
3. Companion can provide objective feedback to the team on food rituals and amount consumed at meals; no personal bias in food intake
4. Well received by individuals transitioning from an inpatient stay to triggers and daily life
5. Many coaches are training/trained to be LCSWs, RDs, or are in recovery
6. Can provide in-home support such as cooking meals with clients

Weaknesses:

1. Can cause splitting if coach does not communicate with team regularly
2. Does not eliminate need for multidisciplinary team
3. Difficult for clients to establish system of trust and safety eating in restaurants with a coach they have just met
4. Client may be too engaged in symptoms and too malnourished for the services to beneficial
5. Coaches/companions need to be trained, and there is no formal training available to date

Each meal support option has its strengths and weaknesses. Talk with your team to determine which method may suit yourself or your client the best. One individual could potentially start with one method such as family meal support and eventually progress to a mindful group with peers. Refer to www.iaedp.com to find professionals certified as eating disorder specialists (CEDS, CEDRD, CEDRN) and www.NEDA.com for free information on eating disorders.

About the author -

A Registered Dietitian, Certified Diabetes Educator and Certified Eating Disorder Registered Dietitian,Laura maintains her private nutrition practice in NYC with over 15 years of experience while specializing in child/adult prevention and treatment of eating disorders.

Laura is the author of “Healthy Habits”—an 8-week-long children’s program educating adults on how to teach children about nutrition and health with a positive, weight neutral approach. Laura founded and manages a blog platform called Mom Dishes It Out for RD moms to share a positive feeding and eating approach. Most recently, Laura authored a continuing education article on the BMI Controversy for Today’s Dietitian.

She is President of the New York chapter of the International Association of Eating Disorder Professionals (iaedp) for her second term. She is a frequent guest on national TV, a public speaker and author of 2 published books.

www.LauraCipulloLLC.com

References -

1. Albano A .M., Glasofer D., Steinglass J., et al. “Rationale for the Application of Exposure and Response Prevention to the Treatment of Anorexia Nervosa.” Int J Eat Disord 44, no. 2 (March 2011):134–41. doi: 10.1002/eat.20784.
2. Corsica J., Hood M., Katterman S., Kleinman B., and Nackers L. “Mindfulness Meditation as an Intervention for Binge Eating, Emotional Eating, and Weight Loss: A Systematic Review. Eat Behav 15, no. 2 (April 2014): 197– 204. doi: 10.1016/j.eatbeh.2014.01.005.
3. Groups for Eating and Body Image Problems. The Women’s Therapy Center Institute Website. http://www.wtci-nyc.org/page4/page4.html. Accessed March 21, 2015.
4. Tribole E. “Intuitive Eating Resources.” 2007–2009. http://www.evelyntribole.com/resources/intuitive-eating-articles-studies-support-groups. Accessed March 20, 2015.
5. Tribole E. “Intuitive Eating in the Treatment of Eating Disorders: The Journey of Attunement.” Perspectives 2010. http://www.evelyntribole.com/uploads/Tribole.IntuitiveEating.Eating%20Disorders.2010.pdf. Accessed March 20, 2015.
6. Corsica J., Hood M., Katterman S., Kleinman B., and Nackers L. “Mindfulness Meditation as an Intervention for Binge Eating, Emotional Eating, and Weight Loss: A Systematic Review. Eat Behav 15, no. 2 (April 2014): 197– 204. doi: 10.1016/j.eatbeh.2014.01.005.